Indian Fertility Society Souvenir 2019

1Souvenir / Abstract Book
FERTIVISION
20196-8 December
15th
Annual Congress of
Indian Fertility Society
Theme:BeyondTomorrowOrganised by
www.fertivision2019.com
The Leela Ambience Hotel, Gurugram
New Delhi | India
Souvenir /
Abstract Book

Souvenir / Abstract Book2
We welcome you all for Fertivision 2019, the 15th
Annual Congress of Indian Fertility Society, scheduled to be held on
6th
,7th
and 8th
December 2019 at hotel, The Leela Ambience, Gurugram, New Delhi/NCR, India. The annual congress
of Indian Fertility Society has most sought-after congress in the field of reproductive medicine in just one and a half
decades of exciting scientific journey. Many delegates, not only from India but beyond India as well eagerly wait for this
annual academic bonanza.
The organizing committee, has chosen “Beyond Tomorrow” as the theme for this year’s Fertivision.
With the proposed theme in mind we have designed 10 interactive workshops on first day of the conference. These are
namely – “IFFS Workshop on Do’s and Don’ts in Ovarian Stimulation”, “Reproductive Surgery”, “Ultrasonography/ Im-
aging in Infertility Management”, “Andrology & Semenology”, “Ovum Pick up and Embryo Transfer (With simulators)”,
“Cryobiology” ,“Total Quality Management”, “patient Counselling and Holistic medicine” , “Publish or Perish” and “PGT
and Genomics”.
In the main congress on 7th and 8th December we have put together an exciting and interactive program.We have the
combined expertise of an eminent group of around 20 internationally-renowned faculty and a large group of experienced
Indian faculty to present the latest developments on every aspect of ART. It addresses the needs of practicing gynecol-
ogists, reproductive endocrinologists, embryologists, residents, and fellows who wish to update their knowledge in this
rapidly advancing field.
We have designed the conference in a way that it will promote extensive deliberations among speakers and participants
with question periods, panels, and many opportunities for informal interaction. Care has been taken to ensure that the
postgraduates and fellows get ample opportunities to interact and clear their doubts.
There is a long list of tourist attractions in Delhi(Heart of India) and Gurugram(Millennium City of India) From monu-
ments ,temples , parks , museums, to sprawling malls - Delhi/NCR has so much in store that it won’t stop amusing you.
For nature lovers , Sultanpur bird sanctuary , Sohna lake and Dumdama lake are nearby tourist attractions in Gurugram.
Looking forward to welcoming you all!

Dr. Mujibur Rehman (North East)
M: 9435070660, E: mrahman567@gmail.com
Dr. Uma Shrivastava (Nepal)
M: 977-9851074477, E: dr.ushrivastava@gmail.com
Dr Jayesh S.Amin ( Gujarat)
M: 9824302671, E: dramin@wingshospitals.com
Dr. Papa Dasari (Puducherry)
M: 9442566883, E: dasaripapa@gmail.com
Dr. JK Goel (UP West)
M: 9458702304 E: drjkgoel309@gmail.com
Dr. Anupama Bahadur (Uttarakhand)
M: 9810326959 , E: anupama.bahadur@gmail.com
Dr. Roya Rozati (Telangana)
E: drroyarozati@gmail.com
Dr. Archana Kumari (Jharkhand)
E: dr_karchana@yahoo.co.in
Dr. Syed Sajjad Hussain (Kashmir)
M: 9419000077 E: medageive@gmail.com
Dr. Divyashree P.S (Karnataka)
M: 9663351451 E: dr.divashree@gmail.com
Dr. Firuza Parikh (Mumbai)
M: 9812694923 E: frparikh@gmail.com
Dr. Usha Prasad (Andra Pradesh)
M: +91 91777 44546
Dr Gouri Devi
President
9810023111
gouri48@ridgeivf.com
Dr M Kochhar
Patron
9810018277 / 24352514
drmkochhar@yahoo.com
Dr Nalini Mahajan
Past President
9810087666
dr.nalinimahajan@gmail.com
Dr M Telang
Founder President
9811030476/25822454
drmangalatelang@gmail.com
Dr Kuldeep Jain
Past President
9810018951, 22443069
jainravi6@rediffmail.com
Dr Abha Majumdar
Past President
9810315807
abhamajumdar@hotmail.com
Dr Sonia Malik
Past President
9810122337
sm_doc@southendivf.com
Dr Surveen Ghumman
Editor
9810475476
surveen12@gmail.com
Dr Rashmi Sharma
Jt. Seretary
9810252619
drrashmisharma73@gmail.com
Dr KD Nayar
Sr. Vice President
9810398765
kdnayar@usa.net
Dr Sohani Verma
Immediate Past President
9810116623
drsohaniverma@gmail.com
Dr Shweta Mittal
Jt. editor
9910303056
mshwets@hotmail.com
Dr Neena Malhotra
Treasurer
9891557707
malhotraneena@yahoo.
Dr Gita Radhakrishnan
Vice President
9891178410
gita.radhakrishnan@gmail.com
Dr Sudha Prasad
President Elect
9968604341
drsprasad@yahoo.com
Dr Leena Wadhwa
Web Editor
9910933447, 9818145296
drleena_123@yahoo.co.in
Dr Ritu Khanna
Jt. Treasurer
9415226900
ritukhannayogesh@yahoo.co.in
Dr Pankaj Talwar
Secretary General
9810790063
pankaj_1310@yahoo.co.in
Dr Ritu Jain
9873183030 / 9999600410
vmcgurgaon@gmail.com
EXECUTIVE MEMBERS
Dr Sweta Gupta
8130140007
swetagupta06@yahoo.com
Dr Vandana Bhatia
9891967417
vandanabhatia1971@yahoo.com
Dr Renu Mishra
9811147217
drrenumisra@gmail.com
Dr Tanya Buckshee
9910003731
tanyabrohatgi@gmail.com
Dr Rupali Bassi Goyal
9818331760
rupalibassi@hotmail.com
Dr Nymphaea Walecha
9873855738
nymphaea2006@yahoo.co.in
CHAPTER SECRETARIES
Dr. Renu Makkar (UP)
M: 9415002674
E: renumakker@yahoo.com
Dr. (Mrs) Harinder Kaur Oberoi
(Punjab)
M: 9888030729
E: drhkoberoi@yahoo.in
Dr. Neeru Thakral (Haryana)
M: 9810569387
E: drneeruthakral@gmail.com
Dr. Sangeeta Sinha (Chattisgarh)
M: 9752595605
E: sangeetasinha1988@yahoo.co.in
Dr. Dr Mamta Dighe (Maharashtra)
M: 9881125250
E: mamta_dighe@yahoo.co.in
Dr. Sangita Sharma (Rajasthan)
M: 9549500137
E: sangi237@yahoo.com
Dr. Swati Verma (Greater Chandigarh)
M: 9646004459
E: swati7562@yahoo.com
EXECUTIVE ADVISORS
Dr. Umesh Jindal
M: 9876130501, 0172-2703222
E: drunjindal@gmail.com
Dr. S.N. Basu
M: 9810119072 E: ssndbasu@gmail.com
Dr Sandeep Talwar
M: 9810306455
E: sonutalwar2001@yahoo.co.in
CO-OPTED MEMBERS
Dr. Alka Kriplani
M: 9810828717 E: kriplanialka@gmail.com
Dr. Urvashi Jha
M: 9811029310 / 9350550669
E: urvashipjha@yahoo.com
Dr. R.K. Sharma
M: 9810442301
E: dr_sharma1957@yahoo.co.in
Dr. Jayant Mehta
E: jayantgmehta@gmail.com
Dr. Rama Raju
M: 9849110004
E: krishnaivf@gmail.com
Dr. Shilpi Sud (Vidharba )
M: 9923737304
E: sun_shilpi@yahoo.co.in
Dr. Monica Singh (MP)
M: 9200002833
E: bttbcentre@gmail.com
Dr. Surender Kumar (Jammu)
M: 09419188392
E: drsurender59@gmail.com
Dr. Anita Singh (Bihar)
M: 9334111925
E: anitasinghob@gmail.com
Dr. Alok Sharma (Himachal)
M: 9418477725
E: md.alok@gmail.com
Dr. Suparna Banerjee (West Bengal)
M: 8697475255
E: suparnaban2@gmail.com
Dr K.U.Kunjumoideen (Kerala)
T: 9895983376
E: drkmoideen@gmail.com
Dr. P.M. Gopinath (Tamil Nadu)
M: 04426163884, 9840888878
E: dgopinath@yahoo.com
Dr Gaurav Majumdar
9810794610
gaurav1979@hotmail.com
Team ifs
Governing council

ORGANISING
COMMITTEE

INTERNATIONAL
FACULTY

S.N. TITLE PAGE NO.
1 Workshops 8
2 Scientific Programme 19
3 Messages 26
4 Abstract Orations 35
5 Abstract of Talks in Main Scientific Programme 42
6 Abstract of Talks in Workshops 114
7 Free Communications : Oral/Poster Presentations 136 - 213
INDEX

Workshops
6th
December, 2019

Scientific
PROGRAMME

7th
December2019

21Souvenir / Abstract Book7th
December2019

7th
December2019

December2019

8th
December2019

December2019

MESSAGES

MESSAGE FROM THE
PRESIDENT - IFS
Fertivision 2019, the 15th
National annual conference is being held on 6th
,7th
& 8th
December at Hotel, The Leela Ambience,
Gurugram, New Delhi /NCR, India.
Fertivision is one of the most awaited annual academic events of Indian Fertility Society. This society in the last 2 years
after the new governing council has taken over has added about 1000 members and now has over 2700 members and 9
chapters making a total of 27 chapters. It has conducted over 100 meetings all over India in the last one and half years.The
society has taken active participation in IFFS world congress2019 at Shanghai,ESHRE at Vienna2019 and Middle eastern
fertility societyat Cairo2019.
The conference program has been planned to deliver the recent advances in a most comprehensive manner in the field of
infertility and Assisted Reproductive Technology (ART) befitting the theme of the conference “BEYOND TOMORROW”
Keeping this in view, we have planned 10 very interactive pre-congress workshops and 2 full days of conference with latest
topics in the form of orations, lectures, debates, panel discussions, by the eminent international and national faculties. We
hope that this will not only enrich your current knowledge but also clear all doubts faced in day to day clinical practice.
We have tried to collect all the contents of the lectures and put it into the souvenir so that the delegates can at leisure read
them. The editorial team under the able guidance of Dr. Rashmi Sharma has worked hard towards this.
Please enjoy the academic feast and warm hospitality of historical Delhi city and Millennial Gurugram City.
Wishing you all a very Happy New Year!
Dr. M. Gouri Devi
President
Dr Gouri Devi
Director
Ridge IVF &Gouri Hospitals
Delhi

MESSAGE FROM THE
SECRETARY GENERAL - IFS
Friends,
On behalf of IFS and organizing committee for the 15th
NATIONAL ANNUAL CONFRENCE “FERTIVISION 2019”,
it gives me great pleasure to extend you all a very warm welcome to Delhi, the home town of culture and heritage. Since
the establishment of Indian Fertility Society in 2005, IFS has seen an unbelievable journey from 20 founder members to a
current strength of more than 2700 members in 27 state chapters all over country with some international chapters as well.
Fertivision has become the most awaited annual academic event in the field of infertility adorned with highly respected
internationally and nationally renowned speakers who will share, discuss, debate and dissect significant new developments
and scientific advancements in the field of ART.
We are having an overwhelming response with more than 1200 delegates attending the conference and a wide spectrum of
international and national faculty who are going to contribute to the rich content of the conference. We express our grat-
itude to all the international and national faculty for sharing and imparting knowledge to update the delegates on recent
developments and practices in Reproductive Medicine, Embryology, Genetics, Andrology and many more subjects.
In the last 15 years of IFS, we are constantly making progress. We are having third batch of one-year fellowship training
program in the form of “Diploma in clinical ART” and “Diploma in Clinical Embryology” in collaboration with Amity
University under the UGC guidelines.
IFS has organized various focused meets all over the country especially reaching places and cities which were earlier un-
touched like Nagaland in our Outreach initiative.
IFS is constantly bringing out very diligently made e Bulletins like IFS Conversations, Nexus, ARText, fertility focus, Cata-
lyst and Fertility Synapses for knowledge dissemination. These have been hugely appreciated by one and all.
IFS is also publishing “Fertility Science and Research” peer reviewed journal with latest research and reviews contributed
by experts from all over the world.
Wishing all delegates and faculty a very happy new year!
With warm Regards,
Dr. Pankaj Talwar
Secretary General
Prof (Dr) Pankaj Talwar, VSM
HOD, ART Centre
Manipal Hospital
Dwarka, Delhi

MESSAGE FROM THE
CHIEF GUEST
It is a matter of immense pleasure that Indian Fertility Society is organizing 15thannual conference, Fertivision on 6th
, 7th
and 8th
December 2019.
Parenthood is a very much desired and anticipated role for most human beings ,sonot being able to fulfil that role rep-
resents a major crisis for most couples. Infertility continues to be a major worldwide problem affecting around 27 million
couples in India alone. With the miraculous advancements in the field of reproductive medicine , now it has become pos-
sible to treat many clinical situations which were earlier untreatable .
We realize that there is a huge unmet need for expert ART specialists, centres across the length and breadth of India. I hope
this megaevent will be a great help in this regard.
I extend my warm greetings and felicitations to the organisers and participants . My best wishes for the success of event .
Wishing you a very pleasant and fruitful conference.
Dr Edgar Mocanu
Dr Edgar Mocanu
President- Elect International Federation of Fertility Societies
Immediate Past Chair FIGO REI committee
Honorary senior lecturer in Reproductive Endocrinology

MESSAGE FROM THE
GUEST OF HONOUR
I am delighted to write this message for the 15th
Annual conference of Indian Fertility Society.
India is an overpopulated country, still the importance of treating infertile couples cannot be undermined. The agony that
an infertile couple goes through is great especially since having a child and family is considered to be very important in
social fabric of India. As India is advancing in ART rapidly, it is essential that there should be a law governing it. Surrogacy
bill and ART bill are government’s priority to safeguard interest of patients and doctors as well .
IamveryhappytoseethegreatworkbeingdonebyIndianFertilitySocietyinallaspectsofinfertilityeducation,researchand
propagation of knowledge. I am sure the annual conference with discussions on most recent advancements in reproductive
Medicine by eminent scientists across the globe will be of immense benefit to community and country at large.
Let us join our hands together to share knowledge and experience that will go a long way in helping to build a healthy,
prosperous and developed India.
With Warm Regards,
Dr Mangla Telang
Dr Mangla Telang
Founder President

MESSAGE FROM THE
SCIENTIFIC CHAIRPERSON
It is my immense pleasure to welcome you all to “FERTIVISION 2019”, the 15th
Annual Conference of Indian Fertility
Society.
Since the establishment of the Indian fertility society in 2005, it has steadily grown in stature and is making significant
contributions to the cause of sharing and spreading knowledge about ART across Indian subcontinent. Now in 2019, it has
become a remarkable academic society with membership exceeding 2700 members with 27 state chapters and affiliation to
International Federation of Fertility Societies (IFFS) since 2007.
The society has contributed towards excellent CME programmes, Symposia and Workshops in both basics and advances of
ART. High priority is accorded to activities that would result in clinical application of recent advances in the field of ART.
IFS is now in third year of its one -year fellowship program for both reproductive endocrinologists and embryologist in
collaboration with Amity University.
The theme of the conference this year is “Beyond Tomorrow”. I hope this conference will be a great help in educating and
updating infertility specialists, embryologists, counsellors etc. for recent advances in the field of infertility management.
The conference will act as a stimulant for promotion of research as well in this field.
We have the honor of hosting eminent speakers from all over the world with ample opportunity for interaction among
delegates and expert faculty.
So, I welcome you all and hope that this conference will help you to update your current standards in clinical practice.
With Warm Regards,
Dr Sudha Prasad
Scientific Chairperson, Fertivision
President Elect, Indian Fertility Society
Dr. Sudha Prasad
Scientific Chairperson, Fertivision
President Elect, Indian Fertility Society
Director, Matritava Advanced IVF & Training Centre, Delhi

MESSAGE FROM THE
Chairperson souvenir committee
Fertivision is one of the most awaited annual academic event of Indian fertility Society. We hope that this year’s theme of
the conference “Beyond Tomorrow” would surely offer excellent opportunities for discussion, exchange of views and ideas
on the subject. The deliberations of the conference will help the gynaecologists , embryologists, scientists, counsellors in
providing a new vista of horizon in improving and updating their clinical and scientific calibre .
In order to fulfil our duty towards environment, we are trying to embrace digital, paper free means as far as possible
through Mobile App, website and souvenir on CD rather than book and paper version.
There are 145 research papers being presented by young researchers and this souvenir contains a brief write up on all. It is a
conglomeration of research and conclusions being presented at Fertivision 2019, both by stalwarts and young researchers.
I thank all the contributors for the timely submission of their abstracts. I am sincerely thankful to each and every member
of my team for their invaluable help in preparation of this souvenir.
Hope to see you all at Fertivision 2019!
With Warm Regards,
Dr Rashmi Sharma
Chairperson, Souvenir Committee
Joint Secretary, Indian Fertility Society
Dr. Rashmi Sharma
Joint Secretary, Indian Fertility Society
Director, Origyn Fertility and IVF
New Delhi

INDEX
S.N. TITLE AUTHOR PAGE
Orations
1 Reproductive medicine at crossroads Dr Gouri Devi 36
2 The forgotten men - The reality and advances Prof Sudha Prasad 37
3 The Prevention of mitochondrial disease Dr Jane Stewart 41
Invited Lectures
1 Oxidative stress and DNA fragmentation Dr Ashok Agarwal 43
2 Microfluidics - Where are we? Arne Sunde 44
3 Endoscopy in unexplained infertiliity prior to IVF - The debate continues Dr Anapuma Bahadur 45
4 Endoscopy in unexplained infertiliity prior to IVF Dr Aswathy Kumaran 46
5 Effects of obesity on fertility and early pregnancy Dr Bharti Dhorey Patil 47
6 Mullerian anomaly and fertility outcome Ephia Yasmin 48
7 Objectivity in embryo assessment and operational quality contron in the Lab Eugenia Rocafort 49
8 Surgery in endometriosis limits and limitatins Dr Fessy Louis T 50
9 Day 3 versus Day 5 transfer Dr Geeta Goswamy 51
10 Poor Ovarian Response Dr Gita Khanna 53
11 Regulation or Restrictions? Future of ART in India Dr Himanshu P Bavishi 57
12 Impact of oral ovulogens on COS outcomes Dr J K Goel 58
13 Embryo Fragmentation origin and outcome Dr Jayant G Mehta 59
14 Toxicity in Labware Jenny Spencer 61
15 Adjuvants in POR what does the evidence say? Dr K D Nayar 62
16 Thyroid disorder and infertility Dr Karuna Jha 64
17 Oocyte donation - Use or abuse Dr Kaushal Kadam 65
18 Uterine Anamolies dignostic dilemmas Dr Lakshmi Chirumamilla 66
19 APLA and ART Dr Leena Wadhwa, Dr Jagriti Bhardwaj 67
20 Can Co-enzyme Q 10 Amitochondrial nutrient enhance oocyte and embryo quality Dr Mekhala Dwarkanath 69
21 Physiology of fertilization Dr Muthukumar K 71
22 Higher rates of blastocysts in egg donation cycles using the geri time lapse incubator De Najib Dagher 72
23 Three parent IVF: What are the concerns Dr Namita Kotia 73
24 Gene editing Dr Nathan Treff 74
25 Approach to the male with infertility Dr N Sanjeeva Reddy 75
26 IVF in women over forty Dr Neeru Thakral 77
27 Tubal disease before IVF:to treat or not Dr Nymphea Walecha 78
28 Rare sperm vitrification Dr Pankaj Talwar 79
29 Microfludics: Past, present & future Dr Paresh Makwana 80
30 Should yoga be a integeral part of IVF treatment Dr Poonam Nayar 81
31 Role of urologist in this era of ICSI Rahul Reddy G 82
32 Add-ons in assisted conception-how should we aproach them Dr Raj Mathur 83
33 Artificial Oocyte activation Dr Rajvi H Mehta 84
34 Diagnosis of genital tuberculosis Dr Rashmi Sharma 85
35 Fertilization Failure Dr Ratna Chattoapdhyay 87
36 Ovarian stimulation in PCOS Dr Ritu Jain 88
37 Newer molicules and advancements in management - role of letrozole Dr Roya Rozati 89
38 Redefining genital tuberculosis Dr Rupali Bassi 90
39 Relevance of sperm DNA fragmentation Dr Sayali Kandari 92

40 Current progress and future of uterine transplant Dr Shalini Gainder 94
41 Surrogacy bill 2019 - is it a game changer? Dr Samit Sekhar 96
42 PCOS: This circaian rhythm Dr Shishta Nadda Basu 98
43 Does perinatal outcomes outcomes matter in IVF - self vs donar Dr Shilpi Sud 99
44 Empty follicle sydrome Dr Sangita Sharma 100
45 Sonoendocrinology & monitoring ART Dr Sonal Panchal, Dr C B Nagori 102
46 PCOS microbiome and its implication on clinical presentations Dr Sonia Malik 103
47 Adenomyosis and ART Dr Sushma P Sinha 104
48 Surprises during Oocyte retrieval and embryo transfer Dr Shweta Mittal Gupta 107
49 Does perinatal outcome matter in IVF? Fresh vs Frozen embryos Dr Swati Verma 109
50 Managing complications of ovum pickup Dr Umesh Jindal 111
51 Receptive endometrium - can we identify? Dr Vandana Bhatia 112
52 Ultrasound examination Dr Varun Duggal 113
ABSTRACTS FOR WORKSHOPS 114 - 135
Understanding the peer review process Arne Sunde 115
Automated Computer Semen Analyzers, Home Sperm Testing, Oxidation Reduction Potential:
What is the benefit of these new technologies to the Clinicians?
Dr Ashok Agarwal 116
Genes and PGD Dr Arundhati Athalye 117
Lab Perspectives in OPU Dr Ethiraj Balaji Prasath 118
Testicular Sperms – Freezing, Post Thaw Processing and Outcomes Dr Ethiraj Balaji Prasath 119
No Sperms: What Next Dr Feseena Kunjimoideen 120
Overview of PGT: Dr Firuza Parikh 121
Laparoscopy in Female Genital Tuberculosis Dr J B Sharma 122
Vitrification and Neonatal Outcome Jenny Spencer 124
Contextualizing Infertility, ART and changing gender relations Dr Meerambika Mahapatro 125
Routine Psychosocial Care Dr Poonam Nayar 126
PGS for All or Not: Role of Counseling Dr Prochi Madon 127
Handling of hyperviscous semen samples for IUI/IVF/ICSI Dr Rajvi H Mehta 128
Yoga for the health of the infertility professionals: A practical exposition Dr Rajvi H Mehta 129
Efficacy of Treatment for Seminal Leukocytospermia Dr Randhir Singh 130
Pre-PGT Work Up Mr. Rupesh R. Sanap 132
Embryo Freezing- Selective or For All ? Dr Tanya Rohatgi 133
Meditation and its effects on Stress Management Dr Yash Shekhar 135

ABSTRACT
ORATIONS

DR GOURI DEVI
President, IFS
Director, Ridge IVF
Delhi
Reproductive Medicine
at Crossroads
Nearly five million babies have been born worldwide as the result of assisted reproductive techniques (ART) since the birth
of the first baby conceived using invitro fertilisation(IVF) techniques in 1978.Infertility is regarded as a health problem.
(WHO: 2004.),though not so in every country.
Assisted reproductive technologies are advancing very fast since 1978. Starting from gamete and embryodonation,
proceedures like ICSI,IMSI,PICSI have come into vogue trying to select the best sperm for ART.
For the selection of best embryo,Time lapse technology was introduced,wherein there was no need to change the media
and the embryologist could at leisure decide which embryo is fast progressing and transfer a blastocyst.But then we know
that Blastocyst transfer gives better results, so is Time lapse needed,as it costs the patient more?
Then to select the Euploid embryo, came PGT-A. With it came controversies too. According to Practice committee of
ASRM, A lot of normal embryos are discarded which has the potential to grow given a chance. The debate is still on.
The result of ART is the live pregnancy rate.Whatever technologies we have introduced,the live pregnancy rate has remained
about 30%.So the question arises do we really need to increase the cost to the patient?
Genome editing is another controversial procedure. CRISPER-CAS9 is the most versatile genomic engineering tool created
in the history of molecular biology to date. It can be used in certain genetic disorders to prevent them in future generations
But it like changing the genetic cell line and what happens to future generations is to be seen. A 2017 report of an animal
study using an in vivo CRISPR/Cas9 system showed an unexpected number of off-target mutations, an important signal
that further research is needed before in vivo gene editing techniques can be introduced into humans.
Age limit for ART is another controversy. Many elderly couple are opting for ART. It is the fundamental right of an individual
to procreate. But is it ethically correct to produce children at 60 and 70 yrs of age?
To conclude, ART is a boon to many childless couples. Research and advancements comes at a cost. But our aim should be
to increase the live birth rate with reasonable cost to the patient.
presidential oration

president Elect oration
PROF SUDHA PRASAD
President Elect, IFS
Dir Prof and IVF Coordinator
IVF & Reproductive Biology Centre
Department of Obstetrics and Gynecology
Maulana Azad Medical College, New Delhi
The Forgotten Men-
The Reality & Advances
Infertility is a complex situation which requires a thoughtful approach. Overall, infertility is on the rise with 1 in 6 couples
wishing to conceive being diagnosed as infertile. The use of assisted reproductive technologies (ART) is therefore increasing
at a rate of 5–10% per year, due to greater need [1].
Male factor infertility is the inability to cause pregnancy in a fertile female. If a man has a low sperm count and the woman’s
eggs are diminished, achieving a pregnancy will require treatment for both. Ignoring the man’s compromised fertility and
focussing all effort to make the female partner better fertile often fails miserably achieving pregnancy.
THE REALITY
No new advances in tackling male infertility
Despite half of infertility cases involving male factors, men have been largely neglected in terms of research, diagnosis, and
treatment. Diagnostic methods for male infertility are based on outdated semen assessment methods that have remained
essentially unchanged for the past 50 years. This is surprising given the advancement of molecular and cellular knowledge
around sperm function [1,2]
Unfair burden on women
The primary intervention currently offered to infertile men is intracytoplasmic sperm injection (ICSI). Due to lack of
advances in treatment options for Male factor women are often unfairly exposed to the trauma and complications of an
ART cycle. Women are exposed to these risks even when they are fertile, since ICSI or IVF are the only options for their
male partners.
Declining male fertility
Over the past 40 years, sperm counts worldwide have halved and sperm quality has declined alarmingly with 1 in 20
men currently facing reduced fertility. But while male fertility is declining, little to no research is being translated into
meaningful clinical interventions. Literature evidence 2017 reports a significant decline in sperm counts between 1973 and
2011, based on studies showing 50–60% decline among men unselected by fertility from North America, Europe, Australia
and New Zealand [3].
Age related decline in sperm quality
Research evidence shows plummeting sperm counts and declining sperm quality in men after the age of 40. Increased DNA
damage and mutation rate in older men augment the risk of complex disease in offspring, such as schizophrenia, autism,
and childhood cancer.
THE CURRENT SCENARIO IN MALE FERTILITY MANAGEMENT
Maleinfertilityhasavarietyofcauses,rangingfromgeneticmutationstolifestylechoicestomedicalillnessesormedications.
Recent studies examining DNA fragmentation, capacitation, and advanced paternal age have shed light on previously
unknown topics. The role of conventional male reproductive surgeries aimed at improving or addressing male factor
infertility, such as varicocelectomy and testicular sperm extraction, have recently been studied in an attempt to expand
their narrow indication [4] The initial evaluation for male factor infertility should include a PE performed by an examiner
with appropriate training and expertise, a reproductive history, and at least one properly performed semen analyses [5].
General physical examination and medical history [5,6]
This includes clinical examination and eliciting medical history covering inherited conditions, chronic health problems,

illnesses, injuries or surgeries that could affect fertility. The evaluation covers sexual habits and development during puberty.
A full evaluation by a urologist or other specialist in male reproduction should be carried out if the initial screening
evaluation demonstrates an abnormal PE, an abnormal male reproductive or sexual history, or an abnormal semen analysis
is found.
Further evaluation of the male partner should also be considered in couples with unexplained infertility and in couples in
whom there is a treated female factor and persistent infertility.
Semen Analysis : Conventional semen analysis is commonly used to define semen quality and to predict only quantitative
values. Semen samples should be tested twice after an abstinence period of 2–5 days. The current quality assessment tools
of semen are unable to provide accuracy for predicting fertility status of a man. Therefore, lower reference limits for semen
parameters have been modified several times (1987, 1992, 1999, 2010) in the WHO manual to increase the clinical value of
these parameters for evaluating male fertility [6].
Standardized semen analyses depend on the descriptive analysis of sperm motility, morphology, and concentration,
with a threshold level that must be surpassed to be considered a fertile spermatozoon. Nonetheless, these conventional
parameters are not satisfactory for clinicians since 25% of infertility cases worldwide remain unexplained. Therefore, newer
tests methods have been established to investigate sperm physiology and functions by monitoring characteristics such as
motility, capacitation, the acrosome reaction, reactive oxygen species, sperm DNA damage, chromatin structure, zona
pellucida binding, and sperm-oocyte fusion [1,2].
The future in semen analysis
Recently, more advanced research methods have provided an opportunity to investigate new prediction techniques based
on genomics, proteomics, transcriptomics, and metabolomics. Combination of the current omics and conventional semen
analysis could provide new methods for exploring potential predictors of male fertility.
Post-ejaculation Urinalysis : This help ruling out retrograde ejaculation.
Scrotal Ultrasound : Uses high-frequency sound waves to help see if there is a varicocele or other problems in the testicles
and supporting structures [2].
Hormone testing
Both ASRM and EAU ASRM do not recommend endocrine testing as a primary first line investigation. For example,
the ASRM (2015a) suggest endocrine testing in men with abnormal semen parameters (particularly when the sperm
concentration less (< 10 million/ml), impaired sexual function or clinical findings that suggest a specific endocrinopathy
[5]
Genetic tests : When sperm concentration is extremely low, there could be a genetic cause. A blood test can reveal whether
there are subtle changes in the Y chromosome — signs of a genetic abnormality.
Testicular biopsy or aspiration- TESE, TESA, PESA, MicroTESE etc are various methods to identify and retrieve
spermatozoa for ART in azoospermia patients The Cochrane analysis of existing data suggest here is insufficient evidence
to recommend any specific sperm retrieval technique for azoospermic men undergoing ICSI. In the absence of evidence to
support more invasive or more technically difficult methods, the review authors recommend the least invasive and simplest
technique available [7].
Transrectal ultrasound : A small, lubricated trans rectal transducer is inserted into the rectum to look for blockages of the
ejaculatory ducts and seminal vesicles.
Management
In cases of male infertility, the female partner also is recommended to be checked. This can help to determine if she will
require any specific treatments or if proceeding with assisted reproductive techniques is appropriate.
Treatment include-
Surgery : Severe varicocele requires surgically corrected or an obstructed vas deferens repaired. Prior vasectomies can be
reversed. In cases where no sperm are present in the ejaculate, sperm can often be retrieved directly from the testicles or
epididymis using sperm-retrieval techniques.
Treating infections: Antibiotic treatment might cure an infection of the reproductive tract but doesn’t always restore
fertility.
Treatments for sexual intercourse problems: Medication or counselling can help improve fertility in conditions such as
erectile dysfunction or premature ejaculation.
Hormone treatments and medications : Hormone replacement or medications help in cases where infertility is caused by
high or low levels of certain hormones or problems with the way the body uses hormones.

Antioxidants for male infertility
A 2018 meta-analysis including 26 studies reported a significant positive effect of antioxidant therapy on basic semen
parameters, advanced sperm function, outcomes of assisted reproductive therapy, and live-birth rate. Vitamin E, vitamin
C, carnitines, N-acetyl cysteine, co-enzyme Q10, zinc, selenium, folic acid and lycopene were most commonly used [8].
The 2019 Cochrane review concluded that oral supplementation with antioxidants is thought to improve sperm quality by
reducing oxidative damage. Antioxidants are widely available and inexpensive when compared to other fertility treatments,
however most antioxidants are uncontrolled by regulation and the evidence for their effectiveness is uncertain [9].
Assisted reproductive technology (ART) ART treatments involve obtaining sperm through normal ejaculation, surgical
extraction or from donor individuals, depending on your specific case and wishes. The washed sperm are then inseminated
intra uterine or used to perform in vitro fertilization or intracytoplasmic sperm injection. IVF gives better fertilisation
results than ICSI in couples with male factor subfertility. Pregnancy rates found after IVF and ICSI are comparable for
couple with non-male subfertility [10].
Methods to select/ screen best quality spermatozoa for treatment
Newer modalities to help find the quality and functionality of spermatozoa include test assessing DNS integrity of
spermatozoa. Novel sperm selection techniques like annexin V–magnetic activated cell sorting (annexin V–MACS), zeta
potential selection, electrophoretic systems for the rapid isolation of sperm exhibiting high levels of DNA integrity and
hyaluronic acid binding techniques, have been recently described. Currently, the evidence is insufficient to recommend one
specific method of sperm selection in the case of high sperm DNA fragmentation [11]. DNA fragmentation index value
<30% can decrease fertility success in infertile couples by 1.6-fold [12]
Motile sperm organelle morphology examination (MSOME) has provided an opportunity for intensive selection of
spermatozoa for ICSI. the inclusion of this method into ICSI led to a new technique termed IMSI.
Another novel method of sperm selection based on the ability to bind with hyaluronic acid led to a new method termed
PICSI or HA-ICSI.
SpermSlow is used to decelerate the movement of spermatozoa to allow the selection of viable, mature, and non-fragmented
DNA-containing spermatozoon for ICSI.
The spermatozoa already screened out to be of higher quality by MSOME or Physiologic binding to hyaluronic acid may
be further screened to rule out aneuploidy by either the hypo-osmotic sperm swelling test (HOST) or fluorescence in situ
hybridization (FISH) testing.
The 2019 Cochrane included eight randomised controlled trials with a total of 4147 women. The review concluded that
sperm selected by hyaluronic acid binding may have little or no effect on live birth or clinical pregnancy but may reduce
miscarriage. The effect of Zeta sperm selection on live birth, clinical pregnancy, and miscarriage was uncertain.
Many studies have related the centrifugation steps of the sorting process with sperm DNA damage (13, 14) that may have
long-term effects on embryos’ viability (15). Microfluidics provides the opportunity to sort sperm cells in a faster, gentler
way that more closely mimics the natural selection processes and avoids some of the most detrimental elements of current
sperm sorting techniques. Microfluidic sperm sorting approaches can generally be sorted into three categories: (type 1)
microfluidic devices that isolate only motile sperm; (type 2) microfluidic devices that isolate sperm cells without relying on
sperm motility; (type 3) microfluidic devices for the observation and selection of individual sperm.
The effect of the other selection techniques on live birth, miscarriage, or pregnancy also remained uncertain hence more
research is the need of the hour [16].
What is needed to Further the quality of male fertility management
To improve the treatment of male infertility, in-depth assays for the assessment of sperm quality are required that link with
clinical outcomes
Research targeting lifestyle factors that can impact fertility are urgently needed.
Incorporating sperm screens into primary care check-ups is advisable. Sperm tests should be performed at an early age, to
inform men about their fertility potential and allow them to adopt lifestyle changes to abrogate a fertility crisis
To counter age related sperm quality deterioration consider “social sperm freezing”
Information about reproductive health and fertility must be responsibly and widely disseminated to boys and men
beginning in school sex education programs and throughout their adult lives.
Optimise the male, reduce the fertility treatment burden on his female partner

Medical conditions affecting male infertility a variety of medical comorbid conditions have been found to affect semen
parameters. The mechanism by which medical conditions may impact fertility includes effects on hormonal levels,
impairment of sexual function (including ejaculatory function), or impairment of testicular function /spermatogenesis.
By medically optimizing a man’s health, improvements in medical disease status can improve semen parameters, sexual
function, and fertility potential [4]
Obesity
obesity is associated with male infertility, likely because of hormonal changes secondary to excess adipose tissue. Promoting
awareness to prevent and treat the disease of obesity is very important.
Male in fertility might be reflection suboptimal general health
studies suggest that male infertility may be an early sign of poor overall health. Not only may infertility be the presenting
sign of an underlying medical condition, but men with abnormal semen parameters may be at a higher risk of malignancy.
Other recent studies have touted the semen analysis as a barometer for overall men’s health, correlating decreasing semen
parameters with increased male morbidity and mortality [4]
Research and more research
There is a need for large multi-centre studies to examine the predictive values in semen analysis to identify men likely
to contribute to successful reproductive outcomes. Second, a fundamental problem with developing new therapies or
diagnostic tests for male infertility is the limited understanding of the formation, maturation and physiological workings
of the normal and dysfunctional spermatozoon. There is an urgent requirement to understand these cellular, molecular
biochemical and genetic mechanism(s) in order to formulate appropriate diagnostic assays and rational therapy for the
male [5].
It is time to promote a culture that puts as much emphasis on male as on female reproductive health. It is time to put the
forgotten men centre stage in preconception education and in the development of better methods to diagnose and treat
infertility.
References
1. Ravitsky, V., & Kimmins, S. (2019). The forgotten men: rising rates of male infertility urgently require new approaches for its prevention, diagnosis
and treatment. Biology of reproduction.
2. Khatun A, Rahman MS, Pang MG. Clinical assessment of the male fertility. Obstet Gynecol Sci. 2018;61(2):179–191.
3. Hagai Levine, Niels Jørgensen, Anderson Martino-Andrade, Jaime Mendiola, Dan Weksler-Derri, Irina Mindlis, Rachel Pinotti, Shanna H
Swan, Temporal trends in sperm count: a systematic review and meta-regression analysis, Human Reproduction Update, Volume 23, Issue 6,
November-December 2017, Pages 646–659
4. Fainberg J, Kashanian JA. Recent advances in understanding and managing male infertility. F1000Res. 2019;8: F1000 Faculty Rev-670. Published
2019 May 16.
5. Christopher L R Barratt, Lars Björndahl, Christopher J De Jonge, Dolores J Lamb, Francisco Osorio Martini, Robert McLachlan, Robert D Oates,
Sheryl van der Poel, Bianca St John, Mark Sigman, Rebecca Sokol, Herman Tournaye, the diagnosis of male infertility: an analysis of the evidence
to support the development of global WHO guidance—challenges and future research opportunities, Human Reproduction Update, Volume 23,
Issue 6, November-December 2017, Pages 660–680.
6. Infertility: An overview — A guide for patients. American Society for Reproductive Medicine. https://www.reproductivefacts.org/news-and-
publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/infertility-an-overview-booklet/. Accessed April 4,
2019
7. Proctor M, Johnson N, van Peperstraten AM, Phillipson G. Techniques for surgical retrieval of sperm prior to intra-cytoplasmic sperm injection
(ICSI) for azoospermia. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD002807. DOI: 10.1002/14651858.CD002807.pub3
8. Majzoub A, Agarwal A. Systematic review of antioxidant types and doses in male infertility: Benefits on semen parameters, advanced sperm
function, assisted reproduction and live-birth rate. Arab J Urol. 2018; 16:113–124.
9. Smits RM, Mackenzie-Proctor R, Yazdani A, Stankiewicz MT, Jordan V, Showell MG. Antioxidants for male subfertility. Cochrane Database of
Systematic Reviews 2019, Issue 3. Art.
10. van Rumste MME, Evers JLH, Farquhar C. Intra-cytoplasmic sperm injection versus conventional techniques for oocyte insemination during
in vitro fertilisation in couples with non-male subfertility. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD001301. DOI:
10.1002/14651858.CD001301
11. Barak S, Baker HWG. Clinical Management of Male Infertility. [Updated 2016 Feb 5]. In: Feingold KR, Anawalt B, Boyce A, et al., editors.
Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000.
12. Bungum M, Humaidan P, Axmon A, Spano M, Bungum L, Erenpreiss J, Giwercman A. Hum Reprod. 2007,22:174-9.
13. Rappa KL, Rodriguez HF, Hakkarainen GC, et al. Sperm processing for advanced reproductive technologies: Where are we today? Biotechnol
Adv 2016; 34:578-87.
14. Aitken RJ, De Iuliis GN, Finnie JM, et al. Analysis of the relationships between oxidative stress, DNA damage and sperm vitality in a patient
population: development of diagnostic criteria. Hum Reprod 2010; 25:2415-26.
15. Smith GD, Takayama S. Application of microfluidic technologies to human assisted reproduction. Mol Hum Reprod 2017; 23:257-68.
16. Lepine S, McDowell S, Searle LM, Kroon B, Glujovsky D, Yazdani A. Advanced sperm selection techniques for assisted reproduction. Cochrane
Database of Systematic Reviews 2019, Issue 7. Art. No.: CD010461. DOI: 10.1002/14651858.CD010461.pub3

Oration on Clinical Reproductive Medicine
Dr Jane Stewart
Head of Department
Newcastle Fertility Centre (NFCL). UK
Associate Lecturer Newcastle University
NFCL Person Responsible to HFEA
Chair British Fertility Society
The Prevention
of Mitochondrial
Disease
It is estimated that 1/250 births carries a pathogenic mitochondrial mutation. About 1/8000 women in the UK carry such
a mutation and about 1/1000 adults are affected.
There is a wide range of disorders associated with such mutations and the severity of disease is dependent on the mutation,
the load carried by the individual and other effectors which are largely unknown but may include environmental factors.
There are no known effective treatments for mitochondrial disease.
Mitochondria are the so-called power packs of cells, responsible for energy production. The number of mitochondria in
cells varies depending on cell function but ranges from 1-3000. Uniquely, these organelles contain their own DNA and
mechanism for replication. mtDNA is made up of around 16,500 base pairs, 37 genes 13 of which code for proteins required
for oxidative phosphorylation. Mutations commonly occur within the genome some idiosyncratic and of no pathological
significance however mutations in critical regions can result in significant disease. Since mitochondria are critical to the
function of all tissues, dysfunction may have a global effect and debilitating neurological and non-neurological disease
results producing disorders described by phenotype; mitochondrial encephalopathy, lactic-acidosis and stroke-like episodes
(MELAS), myoclonic epilepsy with ragged red fibres (MERRF), Leigh Syndrome and Leber hereditary optic neuropathy
(LHON) are examples.
Sperm cells contain paternal mitochondria in the mid-piece however these are discarded and destroyed at fertilisation and
play no part in the mitochondrial complement of an embryo nor offspring. An individual’s mitochondria are all maternally
derived. Maternal mitochondria are distributed within oocytes generated when a fetus. There is great potential however
for disproportionate distribution, therefore a woman who herself carries a low level of mutation (ie a small proportion
of abnormal mitochondria) and therefore may be completely unaffected may have eggs with a range of mutational loads
including very high levels resulting in significant disease in her offspring. Indeed a series of neonatal deaths or childhood
mortality has been the presenting feature for many women culminating in the diagnosis for the first time in a family. The
diagnosis has significant implications for the reproductive potential for all female members of that family. That risk of a
“high-load” embryo resulting in a baby or child with devastating disease, or a child who develops disabling problems in
young or later adulthood, is analogous to Russian roulette; there is no prediction for when it might hit. Up to now for
some, for subsequent pregnancy the potential for antenatal screening and the potential for termination of a significantly
affectedfetus has given a possible, if unpalatable choice. For women with high level loads or who are homoplasmic for their
mutation there has been no reprieve.
In Newcastle upon Tyne, UK we have developed a programme based on assisted reproductive technologies to significantly
reduce the load of abnormal mitochondria passed from mother to child, effectively reducing the risk of having an affected
child.
We run a comprehensive patient pathway of risk assessment (mutation and load in woman), medical review (fitness for
treatment and pregnancy) and treatment comprising the potential for pre-implantation diagnosis, mitochondrial donation
or other recommendations as appropriate. The programme has been developed through research by Newcastle Fertility
Centre research team (Newcastle Hospitals NHS Foundation Trust) in conjunction with Newcastle University; Wellcome
Centre for Mitochondrial Research and collaboration with the clinical teams in both the clinical Mitochondrial Centre
and the Fertility Centre for translation into clinical care. This has been possible through the support of NHS England
commissioning and the Human Fertilisation and Embryology Authority (HFEA) regulation and licensing. The PGD
service is one of few worldwide and the mitochondrial donation service for prevention of mitochondrial disease the only
licensed service worldwide.
This programme is a game-changer for women at risk of having a child with mitochondrial disease allowing them the
option to reduce or avoid such a potentially devastating reproductive outcome.
In my oration I will introduce mitochondrial disease, describe the development of the programme and explain the patient
pathway to healthy pregnancy.

Invited
LECTURES

Dr Ashok Agarwal
Professor of Surgery (Urology),
LernerCollegeofMedicine&CaseWesternReserveUniversity
Director, Andrology Center & Reproductive Tissue Bank
Director, American Center for Reproductive Medicine
Staff, Departments of Urology, Ob-Gyn, Immunolgy and
Anatomic Pathology Cleveland Clinic Foundation
Cleveland, Ohio 44195, United States
Oxidative Stress and
DNA Fragmentation
Despite advances in the field of male reproductive health, idiopathic male infertility remains a challenging condition to
diagnose and manage. Semen analysis fails to predict the male fertility potential specifically in unexplained and idiopathic
infertile conditions. After the fertilization, sperm DNA starts to transcribe actively at the 4‐cell stage, contributing to 50%
of the embryonic genome. Therefore, the sperm DNA integrity in the ejaculated sperm is a critical factor for successful
fertilization, embryo development, implantation, and pregnancy. Increasing evidence suggests that oxidative stress (OS)
plays an independent role in the etiology of male infertility, with 30% to 80% of infertile men having elevated seminal
reactive oxygen species levels. OS can negatively affect fertility via a number of pathways, including interference with
capacitation and possible damage to sperm membrane and DNA, which may impair the sperm’s potential to fertilize an
egg and develop into a healthy embryo. Adequate evaluation of male reproductive potential should therefore include an
assessment of sperm OS and sperm DNA fragmentation (SDF) during male fertility evaluation. Patients diagnosed with
varicocele, unexplained infertility, recurrent pregnancy loss, and recurrent failure of assisted reproductive techniques
(ART) and those at risk of lifestyle/environmental exposures are recognized candidates for SDF testing. High rates of
SDF have been demonstrated in the cauda epididymis and ejaculate when compared to testicular sperm, which indicates
the major contributory role of post‐testicular damage in the origin of SDF. A large body of evidences suggests OS as
the primary cause of post‐testicular sperm DNA damage. An imbalance between the production of ROS and scavenging
ability of the antioxidant defense system results in a state of OS. The excessive ROS induces DNA damage either directly
resulting in base oxidation, strand breaks, and chromatin crosslinks or indirectly via activation of sperm caspases and
endonucleases. Augmented intrinsic production of ROS by immature spermatozoa that retains cytoplasmic droplets is the
main cause of sperm DNA damage. Studies have demonstrated the strong association between high seminal levels of ROS
and SDF as well as poor chromatin packaging in infertile men. On a therapeutic level, SDF can help in selecting patients for
varicocelectomy, choosing the ART modality and intervention associated with highest pregnancy and live birth outcomes
and monitoring treatment response in patients with lifestyle risk factors.

Arne Sunde
PhD
Professor emeritus, Department of
Clinical and Molecular Medicine,
Norwegian University of Science & Technology,
Trondheim, Norway
Editor in Chief Human Reproduction Update
Microfluidics –
where are we?
Microfluidics deals with the control and manipulation of fluids in the µl to pl scale. Practical use currently varies from
inkjet printer heads, to DNA-chips and so-called lab-on-chip technology. Transport of liquids in microfluidics system
are very different from “macrofluidics” systems. In microfluidics, surface tension, capillary forces, energy dissipation and
fluidic resistance dominate the system. Transport of liquids in micro-systems is characterised by a low Reynolds number
i.e. the flow is predominantly laminar contrary to “macrofluidics systems where turbulent flow dominates.
The basic technology of microfluidics system is in rapid development and have been introduced in many diagnostic systems.
Lab-on-chip systems have been devised that could perform chemical analysis, genetic analysis including DNA sequencing,
immunological detection and cell sorting. Microfluidics systems may be integrated in closed systems that can be remotely
controlled.
Microfluidics systems can be used for sperm sorting, oocyte and embryo culture, time-lapse, continuous flow replenishment
of culture media or analysis of substances secreted by gametes of embryos and for cryopreservation of gametes and embryos.
These systems are still experimental and most of the data available are from animal models. A major limitation for the
further development of microfluidics systems in ART is that we still do not fully understand the requirements for optimal
culture of gametes and embryos, and we have no consensus on the best system(s) for grading gamete and embryos quality.

Dr Anupama Bahadur
Additional Professor
Department of Obstetrics & Gynaecology
AIIMS, Rishikesh UttarakhandRajlaxmi Mundhra
Assistant Professor
Dep. of Obs & Gyn, AIIMS, Rishikesh Uttarakhand
Endoscopy In Unexplained
Infertility Prior To IVF-
The Debate Continues
Traditionally, unexplained infertility remains a diagnosis of exclusion. A couple is labelled as unexplained infertility only
when all standard recommended clinical investigations yield normal results. The standard investigation of an infertile
couple includes semen analysis to detect male factor infertility, hysterosalpingogram (HSG) in order to evaluate the
patency of fallopian tubes, and assessment of the ovulatory function by evaluating levels of follicle-stimulating hormone
(FSH), luteinizing hormone (LH), Estradiol, and progesterone during the menstrual cycle. It is estimated that aetiologyof
infertility fails to be identified in 30%–40% of infertile couples following standard infertility work up. Majority of cases with
unexplained infertility seek assisted reproductive technologies.
However, there is a constant debate regarding the need to exclude endometrial and intraperitoneal abnormality by hystero-
laparoscopy prior to establishing diagnosis of unexplained infertility. Worldwide, diagnostic laparoscopy is increasingly
bypassed by IVF clinics in an effort to be cost-effective on one hand and on the other hand, to protect patients from
possible hazards of surgical complications and general anaesthesia.Disadvantages of diagnostic laparoscopy include the
need for general anaesthesia, patient’s anxiety and the possibility of adhesion formation. The rationale behind performing
laparoscopy prior to IVF lies in detecting the underlying factor of infertility as the culprit of IVF overuse, in which case it
could be corrected where deemed required but the invasive nature of diagnosis and treatment accounts for the hesitation
in including it in the standard infertility investigation workup. Hence, this place is being reconsidered, especially in case of
normal hysterosalpingogrophy (HSG), because of the advent of assisted reproductive technologies which are more efficient,
and because of the improvement of medical imaging techniques which are more sensitive and specific. It is well established
that the use of laparoscopy in women with decreased ovarian reserve or severe male factor infertility offers no added benefit
as the main treatment will still remain IVF. The major concern and controversy lies in women with endometriosis, tubal
adhesions, history of tubal sterilisation, and uterine fibroids distorting the uterine cavity which could have been benefitted
with endoscopy. A Cochrane review in 2002 concluded that laparoscopic surgery in the treatment of minimal and mild
endometriosis may improve pregnancy success rates, but that the relevant trials have some methodological problems and
further research in this area is needed. Hence, till the time research focusses on its advantages as compared to the risks
associated with its use, endoscopy in unexplained infertility should solely be based on the physician’s decision.

Dr Aswathy Kumaran
Endoscopy in unexplained
infertility prior to IVF
Unexplained infertility (UI) is infertility in which the cause of the fertility impairment cannot be detected by use of
standard diagnostic measures like semen analysis, tests for ovulation and tubal patency. It remains a clinical and scientific
challenge. UI does not mean there is no physical explanation for the infertility, but that is just, medical tests have not
identified any specific problems. Possible aetiologies for UI may include tubal dysfunction, undetectable tubal disease, even
minimal endometriosis, subclinical infections, hostile cervical mucus, subtle ovulatory dysfunction, luteal-phase defect,
immunological variations, subtle endocrine variations, hyperprolactinemia, sperm dysfunction and antisperm antibodies
some genetic, or psychological causes. The current fertility guidelines suggest IVF as the treatment of choice for UI after
two years of expectant management.
Hystero laparoscopy is an integral step of the diagnostic work-up of any infertile couple. It is best to perform
hysterolaparoscopic evaluation within 1 year of unexplained infertility. A thorough endoscopic evaluation gives clarity
about missed fallopian tubal, ovarian or intrauterine causes, occult pelvic intrauterine infections. It allows us to explore the
implantation site.
Laparoscopy can demonstrate previously undetected stage I or II endometriosis or periovarian or peri tubal adhesions in a
substantial proportion of women. Laparoscopy many times might be able to explain the pathology that remained unfound
till then. Mesosalpingeal pathology like paratubal cysts, lipo mesosalpinx, utereovescical adhesions, subtle tuba; pathology
pelvic inflammation can all be revealed on a thorough laparoscopy by the trained reproductive medicine expert which
quickly pave way to optimal fertility management. Sometimes a little adhesiolysis may allow the patient to conceive.
Hysteroscopy, especially office hysteroscopy, saves money, omits stress for the patient. It is an attractive tool to explore the
endometrial cavity as well as to systematically examine the vagina, ectocervix, endocervical canal, endometrial cavity as
well as the tubal ostia. Many tubal causes of infertility can be easily detected from the endometrial cavity like polyps, fine
adhesions or occlusion. These helps explain or solve infertility, avoid IVF in some cases and make the IVF outcomes better
in others. Hysteroscopy evaluates and ensures that the implantation area is optimal. Implantation site is located on the
posterior endometrium at midline 10-15 mm from the fundus. Hysteroscopy can detect tiny lesions at the implantation
site like fine adhesions, polyp or small septum. Implantation failure may be caused by abnormal cytokine expression by
embryos and endometrium. As proved in many studies, endometrial injury would induce release of cytokines that may
increase implantation.
Thus, dual endoscopy i.e. hysterolaparoscopic might explain a good number of cases with unexplained infertility. Endoscopy
can lead way to management more suited to the couples need than IVF or make the IVF outcomes more favourable.

Dr Bharti Dhorepatil
Director
Ssmile Fertility Center, Shree Hospital, Pune
Effects of Obesity on Fertility
and early Pregnancy
Globally, approximately 2.3 billion adults will be overweight and more than 700 million adults will be obese by 2015,
as projected by WHO. Many low-income countries are affected by rising levels of obesity. India has the world’s second-
largest population and its economy is growing rapidly with urbanization, industrialization, and changes in lifestyle—all
of which predispose to obesity and other health-related conditions associated with it. Despite this, the overall prevalence
of overweight adults in India is low and that of undernutrition is high, with obesity most common among women in
urban and high-socioeconomic-status groups. National Family Health Surveys in India indicated an increase in obesity
from 10.6% in 1998–1999 to 14.8% in 2005–2006. Obese women are at increased risk of pregnancy-related complications,
including subfertility, early spontaneous abortion, preeclampsia, and gestational diabetes mellitus (GDM), and are more
likely to require instrumental and/or cesarean delivery than are women of a normal weight.
Effects of obesity on Fertility and Early Pregnancy
Fertility
Obesity is associated with several reproductive disturbances. Body weight influences the timing of menarcheand the
capacity to achieve pregnancy. Early reproductive dysfunction among obese women includes precocious menarche,
irregular menstrual cycles, oligomenorrhea and amenorrhea, and chronic anovulation. A U-shaped relationship between
body weight and fertility has been described.Excess body mass has an independent and deleterious effect on fertility,even
after controlling for confounding factors such as maternal age. Among obese women, subfertility is often related to
ovulatory dysfunction, likely because of the effect of obesity on many neuroendocrine and ovarian functions. Moreover,
obesity creates a state of sex hormone imbalance that is not favour able for reproduction.The negative effect of obesity
on fertility in general also influences the success of assisted reproductive technology. Although some studies report that
clinical pregnancy and delivery rates after IVF or ICSI are not affected by obesity,the evidence in support of a negative effect
on IVF and ICSI success rates is stronger. Obese women undergoing IVF require higher doses of exogenous gonadotropins
to achieve superovulation and have fewer oocytes retrieved.24,25 There is also a direct relationship between BMI and the
risk of miscarriage with a progressively increasing risk in overweight, obese, and very obese groups (adjusted OR 1.29, 1.71,
and 2.19, respectively).One of the largest cohort studies examining the success rate of IVF determined that women with a
BMI > 27 kg/m2 had significantly lower delivery rates (OR 0.67) than women with a BMI 20 kg/m2 to 27 kg/m2, and that
a BMI > 27 kg/m2 reduced the chance of a live birth in the first IVF cycle by 33%.
Early Pregnancy
Obesity has been identified as an independent risk factor for miscarriage in women receiving fertility treatments.
However, reports on the risk of miscarriage in obese women who conceive naturally are scarce and contradic-tory. In a
recent case-control study, the risks of early miscarriage (at 6–12 weeks of gestational age) and recurrent early miscarriage
were significantly higher among obese women (OR 1.2 and 3.5, respectively). Further research is needed regarding the
association between obesity and miscarriage in naturally conceived pregnancies.

Ephia Yasmin
MRCOG, MD
Consultant Gynaecologist with Sub-specialist
Accreditation in Reproductive Medicine & Surgery
University College London Hospital (UCLH) London
Müllerian anomaly
and Fertility
outcome
Assessing outcomes of Müllerian anomalies is fraught with problems because there was no consensus of the classification
of Müllerian anomalies. After the initial AFS classification, the CONUTA classification also met with criticism. However
with the advent of 3D scanning, the assessment of Müllerian anomalies have been easier. Anomalies range from absence of
uterus (MRKH) to duplication of the Müllerian system. Reproductive outcome depends on the type of anomaly. Most non-
obstructive anomalies when associated with normal functional uteruses do not cause infertility. The risk of miscarriage and
preterm birth are higher. Obstructive anomalies carry the risk of adenomyosis and endometriosis.
Knowledge of Müllerian anomalies is important to counsel the patient, avoid unnecessary intervention whilst also
considering timely intervention in certain types of obstructed anomalies. Randomised control trials are generally lacking
as incidence of these anomalies are low. The talk will focus on the different types of Müllerian abnormalities, criteria for
diagnosis, treatment and reproductive outcome.

Eugènia Rocafort
Senior Clinical Embryologist
Department of AssistedReproduction
Quironsalud Hospital and Teknon Medical
Center (Barcelona
Objectivity in Embryo
Assessment and
Operational Quality
Control in the Lab
In ART, most of the processes and manipulation are performed by humans leading to a wide inter - and intra -
operatorvariation. One of the most critical aspects is embryo selection by morpholgy assesment. The agreement is low
among even experienced embryologists as to how to predict the viability of an individual embryo based up on its appearance
at all embryo stages, including the blastocyst stage.
Ideally there quirements for the best embryo selection technique should include standardization, ease of assessment,
objectivity, minimal harm to the embryo and a high correlation with pregnancy rates. Automated time-lapse imaging
system shave the potential to meet these requirements. Many studies have demonstrated superior clinical outcomes from
embryos developed in these specialized systems compared with standard incubators in combination with multi variable
algorithms for selection. Nowadays, time-lapse Systems are also incorporating the published algorithms to facilitate IVFs
labs to use them on a daily clinical practices and combine them with morphological information. Moreover, it seems likely
that other screening tools used in tandem, such as PGT-A, may help to improve even more these outcomes.
Another critical factor that can be optimised by automated tools is the witness process. On average, embryologists
manually double check identification of patients and their consumables forup to six movements per cycle. In some clinics,
this amounts to almost 50,000 critical checks per year, that’s 50,000 chances of variable human error and 2,250 hours of
productivity lost to witnessing interruptions.
Electronic Witnessing Systems enables the electronic traceability of the staff members performing each procedure and the
time it was performed, and increases the efficiency of the whole process. Moreover, Automated witness Systems ensures
safety, eficiency and standarization throughout all the clinical processes, giving precise information from every operator.
Thanks to that, operational quality control can be performed more accurately and combined with key performance
indicators, all processes in the lab are monitored easily. Systems to monitor clinical and laboratorial performance have
gained much importance. In fact, in many countries are stablishing quality control audits to ensure that SOPs (Standard
Operation Procedures) are followed and good practices aplied equally for every patient. For this reason, external consulting
is emerging for helping IVF labs to improve objectively clinicians and embryologists performance to achieve the best
results.

Dr Fessy Louis T
Senior Consultant and Associate Professor,
Department of Reproductive Medicine and Surgery, AM-
RITA Fertility Centre,
AIMS-AmritaInstituteofMedicalSciences,Kochi,Kerala
Surgery in Endometriosis
Limits and Limitations
Endometriosis occurs when the tissue that normally lines the inside of the uterus (endometrium) is found outside the uterus.
Endometriosis may grow on the outside of uterus, ovaries, and tubes and even on bladder or intestines. This tissue can
irritate structures that it touches, causing pain and adhesions on these organs. Although a definite causal relationship has
not been confirmed, endometriosis is associated with infertility. Endometriosis is a common disease that occurs in 6 to 10%
of reproductive-age women. Approximately 25 to 50% of infertile women have endometriosis, and 30 to 50% of women with
endometriosis are infertile.Multiple mechanisms contribute to decreased fertility in these women.
The nature of the relationship between endometriosis and infertility remains controversial. The association between
endometriosis and infertility is especially evident for advanced stages of the disease. There are many reasons why endometriosis
might compromise fertility but they are basically connected with ovulatory abnormalities and distorted pelvic anatomy.
Autoimmune disorders have also been implicated in the pathogenesis and possible association between endometriosis and
periodontal disease.
The current management of endometriosis includes expectant, medical, surgical and combined therapies and the selection
is based on the staging of the disease proposed by the American Fertility Society (AFS). The surgical management of
endometriosis has largely been guided by patient symptoms, especially, complaints of dysmenorrhea, dyspareunia, dyschezia,
and chronic pelvic pain. While the benefits of surgical management for improvement of endometriosis-related symptoms have
been established, there is much debate about the utility of surgery in management of endometriosis-related infertility. Ovarian
endometrial cysts are indications for reconstructive surgery. The extent of adhesions and fibrosis, rather than the size of the
cyst, determine the surgical outcome.
The most widely used staging system of endometriosis is the revised American Fertility Society classification (r-AFS
classification). The r-AFS classification is used to predict the recurrence potential of endometriosis after surgery. However,
it has limited predictive ability for pregnancy after surgery. The endometriosis fertility index (EFI), proposed by Adamson
and Pasta in 2010, is used to predict fecundity after endometriosis surgery. The variable used to create the EFI was the least
function score. It is the sum of those scores determined intraoperatively after surgical intervention that describe the function
of the tube, fimbria, and ovary on both sides.
The main visible features of the minimal and mild stages of endometriosis are peritoneal or ovarian endometriotic implants
and filmy adhesions on the fallopian tubes or ovaries. The causal link between these lesions and infertility is much debated,
also the value of resection or ablation of these lesions as a treatment for infertility. Operative laparoscopy for endometriosis
consists of electrocautery or laser destruction of endometriotic implants and adhesiolysis.
Laparoscopic surgical removal of endometriosis is recognized as being effective in improving fertility in stage I and II
endometriosis. RCTs have failed to demonstrate the benefit of excision over ablation, it is recommended to excise lesions
where possible, especially deep endometriosis where pain is present. No RCTs have to date assessed whether surgery improves
fertility in stage III and IV endometriosis and in deep endometriosis.Post-operative medical adjunct therapy may delay
pregnancy at a time when fertility has been improved by surgery.
In endometriomas laparoscopic excision (cystectomy) whenever possible for endometriomas >4 cm in diameter improves
fertility more than ablation (drainage and coagulation). The functional appearance of the fallopian tubes and ovariesat the
end of the laparoscopic procedure appears to contribute to the chance of natural conception post-operatively.Much care needs
to be taken in identification of tissue planes and careful dissection of the endometrioma to avoid removing normal ovarian
tissue and thus impacting on ovarian reserve. In young women, for whom fertility is a consideration especially if bilateral
endometrioma, surgical cystectomy must be not be preferred to ART if ovarian reserve is poor.
In patients with recurrent endometriosis two cycles of IVF might be more effective than repeat surgery. Pregnancy rate
after repeat surgery is lower, approximately half that of after first surgery. But surgery should be considered for women with
endometriosis-related infertility who continue to be symptomatic or have enlarging endometriomas, and women for whom
IVF is declined.
In conclusion, although surgical management for infertility due to endometriosis can improve pregnancy rates, the overall
magnitude of effect is unknown. The endometriosis fertility index (EFI) is a simple, robust, and validated clinical tool that
predicts pregnancy rates for patients after surgical staging of endometriosis. The EFI is very useful in developing treatment
plans in infertile patients with endometriosis.

Dr. Geeta Goswami
M.Sc., Ph. D
Scientific Director, Ridge IVF Pvt. Ltd.
Day 3 Versus
Day 5 Transfer
Transfer of embryos following in-vitro fertilization (IVF)is typically done either at the cleavage stage, or at the blastocyst
stage. With advancements in media and embryo culture, extended culture of human embryos till day 5 has been promoted
to increase the efficiency of IVF treatments by selecting the embryos with the best implantation potential and by reducing
the number of embryos replaced, thereby reducing the risk of multiple pregnancy.
Although extending the embryo culture to day 5 has raised some concerns regarding safety and costs, there are some
presumptive theoretical advantages to blastocyst embryo transfer. Day 5 transfer is more closer to a naturally occurring
pregnancy where the embryo is thought to traverse the uteroDr. tubal junction late on day 3 or early on day 4, and so the
timing of exposure of the embryo to the uterine environment at blastocyst stage is more appropriate (Oliviennes et al., 1994;
Kaufmann et al., 1995).Second,byextendingthedurationofcultureforanadditional 2–3 days, activation of the embryonic
genome on day 3 occurs and this, in turn, enables identiﬁcation of those embryos capable of forming blastocysts in-vitrowith
the highest implantation potential (Gardner et al, 1998). Therefore, blastocyst transfer may increase the pregnancy rate per
embryo transferred, which is especially relevant in the context of singleembryotransferpoliciesintendedtoreducemultiple
gestations.
Despite the above potential advantages, there are also some theoretical disadvantages associated with extended culture.
First, it is likely that the in-vitro environment is inferior to that in-vivo, which may lead to some embryos failing to
blastulate in culture that would have implanted successfully if transferred at the cleavage stage. Second, in-vitro culture
beyond embryonic genomic activation couldpotentiallyharmtheembryo especially in terms of epigenetics. Monozygotic
twinning, biased gender ratio and neonatal complications have been reported with blastocyst transfers (Kallen et al., 2010;
Maheshwari et al., 2013; Dar et al., 2014).Ernstad et al., (2016) found no increased risk of birth defects in singletons
born after blastocyst transfer. In fact, they found perinatal mortality and risk of placental complications were higher in
the blastocyst group as compared to the cleavage-stage group. They recommended that theseobservations need further
investigations. Moreso,severalstudies haveshownanincreasedincidenceoftransfercancellation and a lower number of
embryos cryopreserved coupled with blastocyst-stage transfer.
Day 3 transfer provides adequate exposure of the embryo to the endometrium providing more time for crosstalk between
the two, helping to enhance endometrial receptivity.Ovarian stimulation results in supra physiological levels of estrogen
and progesterone that enhances endometrial development. The endometrium is advanced to such an extent that a Day
3 endometrium of a stimulated cycle may be equivalent to a day 5 endometrium of a natural cycle (Ubaldi et al., 1997;
Nikas et al., 1999; Kolibianakis et al., 2002). Thus, day 3 transfer reduces the risk of missing the window of implantation.
Alikani et al (2000) observed a 33% pregnancy rate when these embryos were transferred on day 3 but they failed to
achieve pregnancies after Day 5 transfers.Thus, extended culture should be limited to only those patients whose embryos
demonstrate optimal development during the first three days of culture.It has been shown that the number of 8-celled
embryos on day 3 is the decisive factor for embryo transfer (Racowsky et al., 2000). The same study showed that embryos
resulting from oocytes with cytoplasmic anomalies such as vacuoles and severe granulations also do better with day 3
embryo transfers compared to day 5.
Studies have shown conflicting results concerning the superiority of day 5 embryo transfer as compared with transfer
on day 2 or day 3.A systematic review and meta-analysis by Martins et al., (2017) has shown that there was no difference
in live birth/ongoing pregnancy, clinical pregnancy, miscarriage or cumulative pregnancy when comparing the transfer
of blastocysts against the transfer of cleavage-stage embryos. There was moderate-quality evidence of a decrease in the
number of women with surplus embryos after the blastocyst-stage embryo transfer.The Cochrane Review (2016) concluded
that blastocyst transfer did not give superior outcome compared to cleavage stage transfer. According to ASRM and NICE
guidelines, blastocyst transfers are associated with decreased number of embryos available for transfer and thus, there is an
increased risk of failure to transfer and cycle cancellation.

A retrospective analysis of one year data of 527 cycles from our centre also showed no difference between day 3 and day 5
transfers (Fisher’s exact test gave p-value: 0.3187; 0.6714; 0.1142 for clinical pregnancy rate, implantation rate and ongoing
pregnancy rate respectively which is statistically nonsignificant)(unpublished).
There is no consensus as far as the ideal day of embryo transfer is concerned. Patient’swell-informed decision and clinical
judgement based on quality of embryos, quantity of embryos, risk of multiples, past IVF cycle history should be taken into
account while deciding the day of embryo transfer.
References:
1. Alikani M, Calderon G, Tomkin G et al. 2000 Cleavage anomalies in early human embryos and survival after prolonged
culture. Human Reproduction 15, 2634–2643.
2. Dar S, Lazer T, Shah PS, Librach CL. Neonatal outcomes among singleton births after blastocyst versus cleavage stage
embryo transfer: a systematic review and meta-analysis. Hum Reprod Update 2014; 20: 439–448. 53.
3. Gardner DK, Vella P, Lane M et al. 1998 Culture and transfer of human blastocysts increases implantation rates and
reduces the need for multiple embryo transfers. Fertility and Sterility 69, 84–88.
4. Kallen B, Finnstrom O, Lindam A, Nilsson E, Nygren KG, Olausson PO. Blastocyst versus cleavage stage transfer in in
vitro fertilization: differences in neonatal outcome? Fertil Steril 2010;94:1680-3.
5. Kolibianakis E, Bourgain C, Albano C et al. 2002 Effect of ovarian stimulation with recombinant follicle-stimulating
hormone, gonadotropin releasing hormone antagonists, and human chorionic gonadotropin on endometrial
maturation on the day of oocyte pick-up. Fertility and Sterility 78, 1025–1029.
6. Maheshwari A, Kalampokas T, Davidson J, Bhattacharya S. Obstetric and perinatal outcomes in singleton pregnancies
resulting from the transfer of blastocyst-stageversuscleavage-stageembryosgeneratedthroughinvitrofertilization
treatment: a systematic review and meta-analysis. Fertil Steril 2013.
7. Martins WP, Nastri CO, Rienzi L et al., 2017 Blastocyst vs cleavage-stage embryo transfer: systematic review and meta-
analysis of reproductive outcomes. Ultrasound Obstet Gynecol, 49: 583–591
8. Nikas G, Develioglu OH, Toner JP et al. 1999 Endometrial pinopodes indicate a shift in the window of receptivity in
IVF cycles. Human Reproduction 14, 787–792.
9. Olivennes F, Hazout A, Lelaidier C et al. 1994 Four indications for embryo transfer at the blastocyst stage. Human
Reproduction 9, 2367–2373.
10. Racowsky C, Jackson KV, Cekleniak NA et al. 2000 The number of eight-cell embryos is a key determinant for selecting
day 3 or day 5 transfer. Fertility and Sterility 73, 558–564.
11. Ubaldi F, Bourgain C, Tournaye H et al. 1997 Endometrial evaluation by aspiration biopsy on the day of oocyte retrieval
in the embryo transfer cycles in patients with serum progesterone rise during the follicular phase. Fertility and Sterility
67, 521–526.

Dr Gita Khanna
Scientific Director, ART Unit, High Risk Pregnancy Unit
& Endoscopy Surgery Unit, Ajanta Hospital & IVF centre Lucknow
President – Association of Private Gynaecologist(APGL), Lucknow
Vice President – LOGS, {FOGSI} Lucknow
Founder Secretory – Indian Fertility Society (IFS), U.P Chapter
Poor Ovarian
Response
Newer classification of Poor Responders – Has it made a difference?
The incidence of poor ovarian response in IVF
Poor Ovarian Response is a big ongoing challenge to reproductive endocrinologists and infertility specialists (REIs) world
over.
Poor Responders : Why should you identify them?
• To individualize stimulation protocol
• To diagnose them and start early treatment.
• To counsel them properly regarding prognosis and success rates. When to cancel or stop treatment for them and
when to counsel for Oocyte Donation
There were nearly 41 definitions given to POR in the past which led to wide heterogeneity in POR definitions. Heterogeneous
definitions and study designs made it difficult to draw valid conclusions.The first structured definition was given by the
Bologna Criteria in ESHRE 2011.
According to the Bologna ESHRE (2011) Criteria “poor ovarian responders” should be considered when patients have at
least two out of the three features:
(i) Advanced maternal age (=>40 years)
(ii) A previous POR (<=3 oocytes with standard stimulation)
(iii) An abnormal ovarian reserve test (ORT) (AFC <5–7 follicles or AMH <0.5–1.1 ng/mL) 1+3 :expected POR
Two episodes of POR after maximal stimulation are sufficient to define a patient as poor responder in the absence of
advanced maternal age or abnormal ORT
(Ferraretti et.al. ESHRE Consenses, HR 2011 )
Clinical Dilemma in Poor Responders by Bologna Criteria
• They include heterogenous subgroups of patients
• Specific characteristic profile of unexpected poor sub optimal responders are not included.
• Age and oocyte number related aneuploidy- Real Ovarian Quality not considered.
Ata B et al Reproductive Bio Medicine Online (2012)
To improve performance of Tailored therapies in such patients and to identify more homogenous population for further
trials led to development of new classification that is POSEIDON Classification in 2016 ;Poor Response to low prognosis.
THE CONCEPT OF POSEIDON STRATIFICATION CAME INTO PICTURE IN 2016
[Patient Oriented Strategies Encompassing IndividualizeDOocyte Number]
POSEIDON WORKING GROUP composes of Reproductive Endocrinologists from 7 dfferent countries
• Carlo Alviggi (Italy),
• Claus Y. Andersen (Denmark),
• Klaus Buhler (Germany),

• Alessandro Conforti (Italy),
• Giuseppe de Placido (Italy),
• Sandro C. Esteves (Brazil) Carlo Alviggi (Italy),
• Claus Y. Andersen (Denmark),
• Klaus Buhler (Germany),
• Alessandro Conforti (Italy),
• Giuseppe de Placido (Italy),
• Sandro C. Esteves (Brazil),
POSEIDON CONCEPT
• IT combined oocyte quality (Sensitivity, reduced mitochondrial activity) along with quantity for STRATIFICATION
of the “Low Prognosis” patients.
In POSEIDON Concept “Hypo-responders” were identified as a distinct category of “Low Prognosis” patients.
A word about HYPORESPONDERS:-
Who are Hyporesponders?
• Young normo gonadotrophic women with normal ORTs who show suboptimal (<4-9oocytes) or unexpected Poor
response to Exogenous FSH.
Even when the Ovarian response is normal > 5 oocyte, they tend to show an increase in required cumulative FSH dose
>2500-3000 IU and also increase in the stimulation length (Hyposensitivity to FSH & LH)
This hyporesponse could be because of decreased sensitivity of the oocytes to FSH stimulations and which in turn may be
because of the genetic polymorphism.
SER- 680 GENOTYPE IS THE FACTOR WHICH CAUSES RESISTANCE TO FSH STIMULATION
Genetic conditions: like 45X mosaicism FMR1 (Fragile X) permutation carrier
Genetic Polymorphisms (SNP) for FSH, LH ,E2& AMH receptors
New definition of low responders
POSEIDON definition of low responders
1) Introduces two new categories of Impaired response
a) “A suboptimal response” defined as the retrieval of four to nine oocytes, which is associated ,at any given age
with a significantly lower live birth rate compared with normal responders i.e . those with 10-15 oocytes.
b) “A hyporesponse”in which a higher dose of gonadotropins and more prolonged stimulation are required to
obtain an adequate number of oocytes (more than three)
2) Combines “qualitative” and “quantitative” parameters namely
a) The age of the patient and the expected aneuploidy rate
b) Biomarkers and functional markers (i.e. AMH and AFC)
35 years of age represent the beginning of age related changes not only in oocytes quantity ,but also in their quality with an
embryo euploidy rate that decreases by 2.4 percentage points for every year increase in female age and blastocyst euploidy
rate that drops from 60% before 35 years to 30 %after 40 years and a subsequent decline in implantation potential.
The uniqueness in POSEIDON concept is the introduction of an intermediate marker or the end point of success in ART:
• The ability to retrieve the number of MII oocytes needed to obtain at least one euploid blastocyst for transfer in each
patient.
• Hence, transfer of euploid embryo maximizes IVF efficiency by offsetting the negative effect of age on implantation
and pregnancy.
What is the mean number of oocytes needed to optimize the likelihood of one euploidblastocyst ?

Pearson’s Correlation
Since we cannot treat apples and oranges alike so the 4 groups of POSEIDON were created.
[Patient Oriented Strategies Encompassing IndividualizeDOocyte Number] 2016
Hypo responder (Unexpected Poor Response)
Hypo responder (Unexpected Poor Response)
GROUP1 (unexpected poor or Suboptimal ovarian responseafter
standardovarianstimulation)
Youngpatients <35 years,
Normal ORT(AFC≥5; AMH≥1.2 ng/ml)
Subgroup1a: <4oocytes
Subgroup1b: 4-9 oocytesretrieved
Poseidon Group, FertilSteril 2016
GROUP2 (unexpected poor or Suboptimal ovarian response after
standard ovarian stimulation)
Older patients ≥35 years ,
Normal ORTs (AFC≥5; AMH≥1.2 ng/ml)
Subgroup2a: <4oocytes
Subgroup2b: 4-9 oocytesretrieved

Low responders (Expected POR)
Low responders (Expected POR)
Conclusion
In conclusion the management of POR has been one of the most challenging aspects of ovarian stimulation for IVF.
Attempts to diagnose and classify these POR cases led to development of BOLONGA criteria but further noticing its
limitations, POSEIDON classification was introduced. But still it could not cover up all cases of poor responders. So the
clinical research based on well designedrandomized trials should carry on in poor prognosis population .The POSEIDON
concept contemplates clinical recommendations with a new pragmatic endpoint, the number of oocytes needed to obtain
one euploid embryo for transfer in each patient. We see this novel initiative as an important working and counselling tool
for ART specialist who handles the low prognosis patient. Meticulously designed studies of sufficient sample size with
proper randomization , allocation concealment and masking should be employed in order to offer evidence of highest
quality regarding the optimal management of POR.
GROUP 3 (Expected poor with Diminished ORTs )
Young patients (<35 years)
Abnormal ORTs (AFC <5; AMH <1.2 ng/ml)
GROUP4 (Expected very poor with Diminished ORTs )
Older patients (≥35 years)
AbnormalORTs(AFC<5; AMH<1.2 ng/ml)

Dr Himanshu P. Bavishi
Regulation or Restrictions?
Future of ART in India
Infertility treatment in general and ART treatment in particular are at unique crossroads in India. The technology is
developing very fast and ART is becoming more and more acceptable to the couples and helping millions of couples to
realize their dreams of having a child.
However, because of the uncontrolled and extremely fast growth of the ART centres, there is always a fear of substandard
medical care and unethical practices. To curb these and standardize the ART practices in India and make this beautiful and
successful technology to benefit maximum number of needy couples, there needs to be regulations.
In India whenever there are regulations, there are problems. The regulations are normally formed by non-medical people
and highly influenced by the ruling political party, NGOs and so many other stakeholders who do not understand the real
science properly. That creates a real problem.
The regulations are formed in such a way that so many times the real needy couples do not get benefit of the technology.
The processes are cumbersome and sometimes not acceptable to the couples, sometimes totally not at all practical. The
provisions in the proposed ART bill and surrogacy bill are detrimental to the whole science.
All the gynec OBGY bodies like FOGSI, IFS, ISAR, INSTAR have represented so many times to Govt. Regarding making
the regulations practical, but it is far from a reality. So many provisions in the bills are such that they kill the purpose of
regulations itself. So much so that the penal provisions in the bills are such that doctors are no longer considered as treatment
providers but “criminals” Practice in India has fast changed and so many non-medical persons, corporates, foreign IVF
clinic chains, and even technology companies have entered into IVF and converted IVF practice into a business. That has
created new problems in the field of ART.
Self-regulation by the clinics is also sometimes not followed properly and that also brings so much of discredit because of
controversial work done by certain clinics for either popularity advantage or financial gains.
In short infertility and ART practice really needs to stabilize in our country and get ready to face the newer challenges.
In my presentation I will talk about various issues related to infertility and ART practices in India and how to overcome the
issues and make ART practice, simple, safe, smart and successful!

Dr. J.K. Goel
Impact of Oral
Ovulogens on COS
Outcomes’
Ovulatorydysfunctionisoneofthecommonreasonsforinfertilityandaccountsforabout40%offemaleinfertility. Majority
of ovulatory dysfunction belongs to WHO class II category. Oral ovulogens constitute the most utilized intervention. They
have the advantage over the gonadotropins of being of lower cost, safer and easy to administer. They are also used to achieve
superovulation during IUI in couples with unexplained infertility. During controlled ovarian hyperstimulation, they can
be combined with gonadotropins for multiple oocyte retrieval for using in IVF protocols especially in poor responders.
Clomiphene citrate is the most common ovulogen being used. Ultrasound monitoring helps to identify the response to
the particular dose. RCOG restricts the no of maximum CC cycles to 12 cycles due to potential threefold increase in risk
of epithelial malignancy of the ovary. Routine administration of hCG as a trigger for follicular rupture during ovulation
induction with clomiphene citrate has not been found to be beneficial. In unexplained infertility, use of CC should be
avoided since it has no proven benefit, though it increases the risk of multiple pregnancy. CC resistance signifies a severe
form of PCOS and treatment options include other ovulogens and in some cases Laparoscopic Ovarian Drilling. In CC
failure, tubal evaluation is warranted to rule out tubal pathologies before moving to alternative options.
Another ovulogen being used is Letrozole, an Aromatase Inhibitor. It has advantage of monofollicular development and
unlike clomiphene citrate, no peripheral antiestrogenic action. It is cleared from peripheral circulation within 48 hours
as compared to clomiphene citrate which remains for 2 weeks. There were initial concerns about teratogenic effect of
Letrozole, but subsequent studies have not shown increased congenital anomaly rate following the drug.
Certain adjuvants to be combined with oral ovulogen are dexamethasone, insulin sensitizer & bromocriptine with or
without gonadotropins in controlled ovarian stimulation. Dexamethasone is being used in late onset congenital adrenal
hyperplasia with normal DHEAS levels whereas metformin is useful in PCOS cases with impaired glucose tolerance or
associated with obesity. Bromocriptine/ Cabergoline are useful in cases with mild hyperprolactinemia.
Oral ovulogens and adjuvants can be combined with gonadotropins in COH where we want to harvest/ retrieve multiple
number of ova to reduce the dose and side effects of gonadotropins thus making the cycle more cost effective.
To conclude, a stepwise approach starting with oral ovulogens, then adjuncts and finally injectables or laparoscopic ovarian
drilling would be the one to be followed, as it would be safer and more cost effective. Clomiphene, was and will be atleast
in near future the drug of choice for ovulation induction due to its proven track record. It is of utmost importance to assess
a given couple individually and plan for targated treatment rather than a blanket one. Further research might open more
gates in this aspect of care with advent of safer and more efficacious alternatives including orally active gonadotropins.

Dr. Jayant G. Mehta
PhD, DipRCPath
Embryo Fragmentation:
Origin & Outcome
A majority of IVF embryos display some degree of fragmentation. Embryo fragmentation results when small cytoplasmic
portions get enclosed by a cell membrane during cell divisions on oocyte activation. These blastomeric fragments are
anucleated and occur during the cytokinetic phase of the cell cycle1.
Although, ‘time-lapse’ photography suggests that fragmentation is a dynamic process, frequently occurring as early as the
first mitotic division (2-3), there are two definitive fragmentations, characterized as stable persistent fragments clearly
detached from blastomeres and pseudo-fragmentation, characterized by a transient appearance during, or shortly after, cell
cleavage, but not detected during later development and being reincorporated into cells (4-5). These observations suggest
that fragmentation may be part of healthy embryo development. However, fragmentation leads to reduced cell volume and
increased disorganization within the embryo (6-7).
The degree of fragmentation an essential biomarker for implantation potential is expressed as the percentage of the
total cytoplasmic volume and is included in almost every embryo scoring system (8-10). Fragmentation <10% usually is
reported as mild, between 10-20% as moderate and >25% as severe. Furthermore, moderate to severe fragmentation is
often associated with blastomere multinucleation and chromosomal abnormalities, most notably mosaicism (11-14).
Abnormal distribution of Epithelial-cadherin, a cell adhesion protein (15), vitally crucial for compaction and blastulation
is associated with abnormal microtubule and mitochondrial distribution(16), and may partly explain the association
between severe fragmentation and reduced blastocyst formation (17-18). As a result, the cells numbers during
differentiation are reduced limiting to trophectoderm in mild fragmentation or include the inner cell mass as well in severe
fragmentations(18-19).
Conclusiveevidencesuggeststhattheoocytecytoplasmicandnuclearcompetencycontributestofragmentationandembryo
development which correlates with the amount of mtDNA (20-22). Studies have reported that in fragmented embryo, a
considerably reduced number of mtDNA poorly distributed within the cytoplasm, results in reduced ATP availability and
poor embryo development (23).
Various groups have considered, programmed cell death or apoptosis(24) as a possible contributor of fragmentation. Using
annexin V staining, an early marker of apoptosis and terminal deoxynucleotidyl transferase-mediated X-deoxyuridine
triphosphate nick end labelling (TUNNEL) staining, overexpression of Apoptotic gene Bcl-2, Bclx, Bax, Fas, and various
caspases, pro-apoptotic genes Harakiri and Caspase-3 have been demonstrated (25-26), in some human embryos with
substantial fragmentation. However, none of these studies is conclusive in suggesting that the fragmentation represents
apoptosis, but it is more likely that apoptosis may occur selectively as a consequence of fragmentation (27).
The influence of maternal age, the role of different gonadotrophins and the length of the time administered for stimulation
may indirectly cause fragmentation due to possibly poor oocyte competency. However, no human studies support this
hypothesis.
Another hypothesis on the origin of fragmentation concerns telomere length. Telomeres are regions of repetitive DNA
at the end of chromosomes that function in protecting chromosomes from damage. Measurements of Telomeres length
germinal vesicle–stage oocytes failed to substantiate a possible contributory role of Telomeres in fragmentation (28).
In conclusion, the available evidence discussed suggests that the presence of significant numbers of fragments, particularly
in conjunction with discrepancies in blastomere symmetry, substantially reduces embryo viability and negatively impacts
clinical outcome. Furthermore, the oocyte competence may be the primary contributor to the origin of fragmentation in
the absence of normal cytokinesis coinciding with the cytoskeletal disorder.

Indian Fertility Society Souvenir 2019

Indian Fertility Society Souvenir 2019

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Indian Fertility Society Souvenir 2019